Robotic and Laparoscopic Appendectomies Are Effective—But with Key Differences

Surgeons have been performing appendectomies for more than a century—and while it continues to be the gold standard treatment for appendicitis—other management options, including robotic appendectomy and antibiotic therapy are proving to be safe alternatives for select patients.

In the “Appendicitis: What’s Old, What’s New?” Panel Session, which took place Monday afternoon, presenters summarized how the treatment of appendicitis has evolved dramatically, particularly over the last 10 years, and cited up-to-date studies—both foundational evidence and new, practice-changing research—examining approaches to both uncomplicated and complicated appendicitis.

“This session seeks to present the entire spectrum of appendicitis management,” said Jill R. Streams, MD, FACS, session moderator. “The central theme of the session is exploring the nuances that we can bring to the diagnosis of appendicitis in the modern era. It’s an exceedingly safe operation with a mortality of less than 1%, but that mortality is not zero. Fortunately, our spectrum of appendicitis management is widening with time for what once seemed to be a very simple disease process.”

One such treatment pathway, a robotic-assisted approach to appendectomy, was first performed by Stephen G. Pereira, MD, FACS, in 2013.

“Robotic appendectomy is here to stay—and that’s because the robotic platform is technologically superior,” said Robert J. Winchell, MD, FACS. He pointed out that the same arguments that were once lobbied against using the laparoscopic approach are now being used to resist the robotic-assisted route: expense, slow speed, learning-related challenges, and diminished universal availability.

“All of these arguments are a red herring of one kind of another,” he said, noting that slow speed is an ineffective measurement for quality and that costs are expected to lessen over time. Dr. Winchell also suggested that robotic procedures provide opportunities for virtual collaboration with junior colleagues in other locations and offer improved ergonomics for surgeons, which he indicated matters “when you’re striving for long-term survival in this business.”

He acknowledged that change is difficult, especially for surgeons who already have a gold-standard approach (laparoscopy) for managing acute uncomplicated appendicitis. “If I try to tell Mozart he needs to learn to play the harmonica, he’s going to want to know why, right? For all of you, surgical traditions die hard. However, robotics is a better tool—full stop.”

Offering a different perspective, Stephanie M. Streit, MD, FACS, identified the benefits of performing a laparoscopic appendectomy.

“The current state of appendectomy still shows that the vast majority of the procedures are done laparoscopically,” said Dr. Streit. “There's a reason for that—we have 40 years of safety and outcomes data that support this approach.”

Citing the ACS National Surgical Quality Improvement Program Participant Use Data File (2016-2021), she revealed that for this time period, 80,065 total appendectomies were reported, with 71,215 laparoscopic, 1,870 open, and 143 robotic. (Dr. Streit acknowledged that the number of robotic-assisted procedures was likely underreported.)

She also cited a recent study that examined outcomes between laparoscopic and robotic appendectomy for a single health system, which was published in the June 2023 issue of Laparoscopic, Endoscopic, and Robotic Surgery. Investigators compared average direct and total costs and found that laparoscopic procedures cost between $3,081 and $7,709, while robotic costs averaged between $7,894 and $13,210.

“This study ultimately showed that robotic versus laparoscopic surgery had the same clinical outcomes but with higher average and indirect and total costs,” Dr. Streit said.

As for procedure duration, laparoscopic median operating time was 46 minutes, while robotic was found to be 71 minutes.

Presenters also compared antibiotic therapy with surgical management outcomes of the disease, with a specific focus on the status of these results as observations now extend to more years than had previously been reported.  

“Antibiotics are a viable option for managing uncomplicated acute appendicitis,” said Patricia Ayoung-Chee, MD, MPH, FACS. “I want to dive a little deeper into the data and show that I believe they are safe—and for those that are a little more skeptical—to show that, at the very least, they are not dangerous.”

Dr. Ayoung-Chee identified key findings from both the Appendicitis Acuta (APPAC) and the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trials. Both studies showed that nonoperative management of uncomplicated acute appendicitis (for suitable patients) resulted in a shorter time away from work or school, a lower overall complication rate at 5 years, and reduced overall cost.

“The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value- and preference-dependent, suggesting that a change in practice toward shared decision-making is necessary,” said Dr. Ayoung-Chee.